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77M ASCITES(?Non portal hypertensive?SBP H/O EMPYEMA ?TB used ATT 6months

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

77 year old male daily wage labourer by occupation president of narayanapuram complaints of abdominal dtension since 3 days 

History of presenting illness:

Patient was apparently a symptomatic until 3 days ago then he had complaints of sudden on set of abdominal distention accompined with twisting type of pain; Dyspnea, constipation decreased urine output, painful defecation aggravated after having food

No complaints of fever headache giddiness

No complaints of bilateral pedal edema no complaints of burning micturition

History of past illness

History of analgesic abuse for knee pain

History of empyema and on ATT 15 years ago

Outside USG: 

1. Liver altered parenchymal ecotextur

2. Cholecystitis

3. Bilateral grade 2 rpd changes with renal cortical cysts 

4. Moderate ascites


PERSONAL HISTORY: 

  • Diet - mixed
  • Appetite- normal
  • Sleep - normal
  • Bowel - regular
  • Bladder - decreased output and burning micturition
  • Allergies- none
  • Addictions-  Beedi 4/ day
  •                         Toddy/ every 3 days


FAMILY HISTORY:

Not significant 


GENERAL EXAMINATION: 

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished 










Vitals : 

Temperature- afebrile

Respiratory rate - 16cpm

Pulse rate - 74 bpm

BP - 120/80 mm Hg.


SYSTEMIC EXAMINATION: 


CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

      Shape of abdomen- distended

  • Umblicus - normal
  • Movements of abdominal wall - moves with respiration 
  • Skin is smooth and shiny;
  • No scars, sinuses.  distended veins present


PALPATION : 

Local rise of temperature present.

Tenderness present in RT hypochondriac region

Tense abdomen 

Guarding absent

Rigidity absent 

Fluid thrill not felt

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 


PERCUSSION: 

Liver span : not detectable 

Fluid thrill: not felt 

Shifting dullness: present


Tympanic note is heard on the midline and dull note is heard on the flanks in supine position


AUSCULTATION: 

Bowel sounds are decreased  


CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++


Gait: normal


INVESTIGATIONS: 


Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 









Treatment :

1. IV fluids Ns@ 50 ml/hr

2. T DOLO 650 MG / PO/TID 


Date:5/3/23
AMC bed no.2
Day 3
S:diffuse pain in hypogastric region( decreases compared to yesterday) stools not passed
O:
O/e patient is c/c/c
Bp-110/90mmhg
Pr-72 pbm
Rr-20cpm
Temp-99F
GRBS - 111 mg/dl
B.Wt - 46 kgs
Abd girth - 76.5 cm
I/O : 1500/750 ml
CVS-s1s2+
RS-BAE+
CNS-NAD
P/A-soft , tender,  Bowel sounds heard

SAAG:-0.8
Sr albumin-2.6
Ascitic albumin-1.8

Ascitic :-
amylase-7.59(normal 25-140)
Sugar-106(normal60-100)
Protien-3.5(normal<2.5)
LDH-180.7(normal 230-460)

Ascitic cell count
Provisional-2400
DLC awaited 

Therapeutic Ascitic Tap done on 5/3/23 350 ml of ascitic fluid was drained 




Date:6/3/23

AMC bed no.2

Day 4

S:diffuse pain in hypogastric region( decreases compared to yesterday) stools not passed

O:

O/e patient is c/c/c

Bp-110/90mmhg

Pr-72 pbm

Rr-20cpm

Temp-99F

GRBS - 111 mg/dl

B.Wt - 46 kgs

Abd girth - 76.5 cm 

I/O : 1500/750 ml

CVS-s1s2+

RS-BAE+

CNS-NAD

P/A-soft , tender,  Bowel sounds heard


HB: 11.1 TO 9.8

TLC : 9800 TO 8700

PLT: 3.82 TO 3.51

RBC : 3.97 TO 3.48 

UREA : 55 TO 114

CREAT : 1.2 TO 1.2

NA+ : 139 TO 137 TO 140

K+ : 4.3 TO 4.1 TO 3.9

CL- : 99 TO 100 TO 101

IONIZED CA : 1.104 TO 1.05


P:

1. IV fluids Ns@  75ml/hr 

2.T DOLO 650 MG / PO/sos  



Date:7/3/23
AMC bed no.2
Day 4
S: Stools passed, abdominal pain present(pain aggravated after eating idly), No fever spikes
O:
O/e patient is c/c/c
Bp-110/80mmhg
Pr-78 pbm
Rr-17cpm
Temp-99F
GRBS - 106mg/dl
B.Wt - 46 kgs
Abd girth - 71.5 cm
I/O : 1500/700 ml
CVS-s1s2+
RS-BAE+
CNS-NFND
P/A-soft , tender,  Bowel sounds heard

HB: 11.1 ---> 9.8 ----> 9.2
TLC : 9800 ---->  8700 ---->8800
PLT: 3.82 ----> 3.51 ---->3.48
RBC : 3.97 ----> 3.48 ----> 3.28
UREA : 55---->  114----> 99----> 85
CREAT : 1.2----> 1.2----> 1.2----> 1.1
NA+ : 139---->  137---->  140----> 137
K+ : 4.3---->  4.1 ----> 3.9----> 3.6
CL- : 99 ---->  100---->  101----> 98
IONIZED CA : 1.03---->   1.05----> 1.0














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